72A Nonshaven Follicular Unit Extraction Techniques
Summary
Keywords: nonshaven FUE direct method pretrimming method Boaventura punch open punch open-window punch NS-FUE
Key Points
•Full shaving of the scalp donor area has traditionally been required in order to perform follicular unit excision (FUE). This is not cosmetically acceptable to many patients.
•Three new methods of performing FUE without shaving (NS-FUE) have emerged: pretrim method, direct method, and use of an open-window “long hair punch.”
•The major advantage of NS-FUE is a substantial improvement in the postoperative appearance of the scalp donor area and faster re-entry into normal life for the patients.
72A.1 Introduction
Follicular unit excision (FUE) has progressed considerably and has become increasingly popular since its introduction in 2002.1 The worldwide census for hair transplantation estimated that among 397,048 hair transplantation procedures performed in 2014 (a 28% increase from 2012), 48.5% were FUE surgeries.2
FUE has associated advantages and disadvantages. Among the advantages, FUE does not create a linear donor scar and is associated with less postoperative pain. In addition, a lot of hair can be transplanted with FUE, even if the donor scalp has limited laxity. Hence, FUE is the chosen method when the donor scalp has minimal laxity. However, in conventional FUE, the donor area must be shaved, which is a major deterrent preventing people from selecting FUE hair transplantation. The strip method creates a linear donor scar and generally results in more postoperative pain than FUE. To avoid a linear donor scar and to minimize postoperative pain while still avoiding shaving, nonshaven FUE (NS-FUE) can be a very good choice.
72A.2 Various Nonshaven Follicular Unit Extraction Techniques
There are various methods of performing NS-FUE.3
First, pretrimming can be incorporated.4 The donor area can be divided into several regions, with a certain number of hairs trimmed in each area for the surgeon to punch during surgery. The length of the trimmed hairs can be adjusted from 1 to 3 mm depending on the purpose of the surgery, location of the recipient site, and other factors (Fig. 72A.1 and Video 72A.1).
Fig. 72A.1 Pretrimmed nonshaven follicular unit excision.
A second technique uses the direct method, omitting the trimming step.5 Trimming and punching take place simultaneously. This method results in hairs as short as 0.3 to 0.8 mm (Fig. 72A.2).
Fig. 72A.2 (a) Direct Nonshaven follicular unit excision (NS-FUE) versus (b) pretrimming NS-FUE.
Another technique is the state-of-the-art long hair NS-FUE method. Hair is inserted through an open window in a specially designed punch tip. In a previous study, this author referred to this apparatus as a “window punch.” Boaventura developed a similar punch, which he also called the “open punch.”6 A better term to describe the form and function of such a punch would be “open-window punch.” Therefore, the term “open-window punch” will be used hereafter. An open-window punch has a slotlike window 0.2 to 0.3 mm in width at its tip, allowing donor harvesting of long hair without the need for pretrimming (Fig. 72A.3). Without preoperative trimming, the harvested follicles by open-window punch can have very long hairs. One can proceed with pretrimming to the desired length before harvesting. Additionally, there is a new punch designed by Trivellini in which the long hair remains intact and also has a groove in it, thus avoiding cutting of the hair during the process.
When applying the pretrimming method of NS-FUE without an open-window punch, hair can be up to 3 mm in length. For hairs longer than 3 mm, it is difficult to insert the splayed hairs of the two-, three- or four-hair follicular units into the punch (Fig. 72A.4).
Fig. 72A.4 When performing nonshaven follicular unit excision with the pretrimming method, it is difficult to insert the punch tip into hairs trimmed longer than 3 mm.
Harvesting with the direct method leaves harvested hairs as short as 0.3 to 0.8 mm, which can be an inadequate length when performing hair transplantation to eyebrows or eyelashes,7,8 where the direction of hair curl can be an important factor, or in pubic transplantation in plump women with an abdominal fat fold, leading to implanted hairs being buried below the skin (Fig. 72A.5).9
NS-FUE is performed with repetition of a series of steps: selection of target hair, movement of the punch to a position just above the hair to be harvested, and creation of an incision by punching. In brief, these steps are selection → targeting → centering → punching → and selection again.
NS-FUE with pretrimming requires much more time for selection and targeting process, because the previously trimmed target hair must be located. In contrast, direct FUE allows movement from a previous punch site to the next nearest target hair, thus shortening the time required between steps. Pretrimming also requires extra time to trim hairs prior to surgery. Scissors with sharp and narrow ends, such as iris scissors, are suitable for pretrimming.
Longer operation time often results in fatigue and loss of concentration for the surgeon and the patient, potentially resulting in a higher transection rate and consequently a longer out-of-body time and lower graft survival rate.
The direct punching method allows for a faster punching duration and does not require extra time for pretrimming. Overtrimming, which allows for easier punching, is not needed because the targeted hair is cut by the punch tip. The direct method has a longer learning curve and surgical expertise is required to identify the exact hair exit angle and direction.
Some clinicians believe that the punch tip becomes dull very quickly in the direct method, but the author has noted no difference in the timing of replacement of punch tips between the two methods. This will vary depending on the punch type, manufacturer, and thickness of the punch tip, the skin type, and the hair thickness. Furthermore, it takes only 30 to 40 seconds to change the punch tip.
A comparison of the advantages and disadvantages of the two methods is shown in Table 72A.1 and Table 72A.2.
Table 72A.1 Advantages and disadvantages of the pretrimming method
Pros | Cons |
Easier centering | Needs extra time and effort to pretrim the hairs |
Shorter learning curve | The assistant selects the hairs to be punched (not always) |
Hair length control (longer hair) | Overtrimming |
Difficult to identify the next target hair (especially wider donor area, smaller amount of grafts) | |
Longer operation time |
Table 72A.2 Advantages and disadvantages of the direct method
Pros | Cons |
Faster | Longer learning curve |
Physician controls the whole procedure | Shorter hair |
The target hair is selected by the surgeon | More difficult to identify the hair exit angle and direction |
72A.3 Indications and Contraindications
Fundamentally, NS-FUE is a suitable and useful harvesting method for patients who are not candidates for the strip harvest method because of insufficient donor site laxity and for those who are strongly opposed to strip surgery for other reasons. However, this technique requires the skill and capability of a well-trained surgeon and surgical team for optimum results.
Moreover, it is important to select the appropriate NS-FUE method (direct method, pretrimming method, or use of an open-window punch) based on the length of hair, location of the recipient site, purpose of the surgery, hair type, and other factors (Fig. 72A.6and Table 72A‑3).
Fig. 72A.6 Comparison of surgical methods according to different hair lengths.
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